Provider Demographics
NPI:1124127873
Name:DESMOND, KELLY C (REGISTERED DIETICIAN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:DESMOND
Suffix:
Gender:F
Credentials:REGISTERED DIETICIAN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:C
Other - Last Name:CUTILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED DIETICIAN
Mailing Address - Street 1:1417 BATTLEFIELD BLVD N
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4516
Mailing Address - Country:US
Mailing Address - Phone:757-623-0005
Mailing Address - Fax:
Practice Address - Street 1:1745 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2435
Practice Address - Country:US
Practice Address - Phone:757-496-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL934551133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ32217Medicare UPIN
VA006276T28Medicare ID - Type Unspecified